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Fracture of the occipital condyle caused by minor trauma in child Thomas Kapapa a, * , Christoph A. Tschan b , Kathrin Ko ¨nig b , Arkadius Schlesinger c , Bernd Haubitz c , Hartmut Becker c , Matthias Zumkeller d , Rickels Eckhard a a Department of Neurosurgery, University Ulm, 89070 Ulm, Germany b Department of Neurosurgery, Medizinische Hochschule Hannover, 30625 Hannover, Germany c Department of Neuroradiology, Medizinische Hochschule Hannover, 30625 Hannover, Germany d Department of Neurosurgery, Klinikum Minden, 32427 Minden, Germany Abstract We report a case of fractured occipital condyle caused by minor trauma accompanied by light pain on palpation at the lateral cervical trigonum. A 15-year-old boy complained of nuchal pain, particularly pain on palpation at the left lateral cervical trigonum in the absence of neurologic deficits after head deceleration trauma. Computed tomography demonstrated a unilateral nonluxated fracture of the occipital condyle. Owing to consequent immobilization by means of cervical orthosis, pain disappeared after the first 48 hours. Follow-up examination 4 weeks later showed no neurologic deficits. The boy had no severe impairment of movements at the cervical spine. D 2006 Elsevier Inc. All rights reserved. The presence of an occipital condyle fracture after head injury is seldom seen, especially when diagnosed in the absence of neurologic deficits, or even worse, if it is presented in childhood with nonspecific complaints. 1. Patient and method A 15-year-old boy was playing on a carousel with his classmates in the schoolyard. While driving around, he lost hold and hit sandy ground with the left side of his head. Trauma was reported as an axial torsion movement. At the scene of the accident, the boy had his cervical spine immobilized by a stiff-neck collar (Laerdal Medical GmbH & Puchheim, Germany). No initial loss of consciousness or signs of neurologic deficits were observed. At the emergency department, the boy reported a progressive pain in the neck as well as at the left cervical trigonum after palpation. He kept his head in a fixed position. Subsequent neurologic exami- nation showed no abnormalities. Computed cranial tomog- raphy (CT) excluded intracranial signs of trauma. An axial spiral CT scan (1.25-mm slice thickness) with high-resolution algorithm gave hints of irregularity of the craniocervical junction. Two-dimensional reformation of the craniocervical junction and the remaining cervical spine showed a fracture of the left occipital condyle without dislocation of the fragment (Figs. 1 and 2). The medulla was not affected. Hence, there was no need for acute neurosurgical interven- tion. After being provided with a rigid collar, the boy was given light pain medication and was monitored under clinical conditions. Pain medication was discontinued after 48 hours. 0022-3468/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2006.05.036 * Corresponding author. Neurochirurgische Klinik, Albert-Einstein- Universit7tsklinikum Ulm, 89075 Ulm, Germany. Tel.: +49 731 50041951; fax: +49 731 50041969. E-mail address: [email protected] (T. Kapapa). Index words: Fracture of occipital condyle; Whiplash injury; Neck pain; Spinal injuries; Head trauma Journal of Pediatric Surgery (2006) 41, 1774 – 1776 www.elsevier.com/locate/jpedsurg

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Page 1: Fracture of the occipital condyle caused by minor trauma in child

www.elsevier.com/locate/jpedsurg

Fracture of the occipital condyle caused byminor trauma in child

Thomas Kapapaa,*, Christoph A. Tschanb, Kathrin Konigb, Arkadius Schlesingerc,Bernd Haubitzc, Hartmut Beckerc, Matthias Zumkellerd, Rickels Eckharda

aDepartment of Neurosurgery, University Ulm, 89070 Ulm, GermanybDepartment of Neurosurgery, Medizinische Hochschule Hannover, 30625 Hannover, GermanycDepartment of Neuroradiology, Medizinische Hochschule Hannover, 30625 Hannover, GermanydDepartment of Neurosurgery, Klinikum Minden, 32427 Minden, Germany

0022-3468/$ – see front matter D 2006

doi:10.1016/j.jpedsurg.2006.05.036

* Corresponding author. Neurochir

Universit7tsklinikum Ulm, 89075 Ulm, G

fax: +49 731 50041969.

E-mail address: thomas.kapapa@uni

Index words:Fracture of

occipital condyle;

Whiplash injury;

Neck pain;

Spinal injuries;

Head trauma

Abstract We report a case of fractured occipital condyle caused by minor trauma accompanied by light

pain on palpation at the lateral cervical trigonum. A 15-year-old boy complained of nuchal pain,

particularly pain on palpation at the left lateral cervical trigonum in the absence of neurologic deficits

after head deceleration trauma. Computed tomography demonstrated a unilateral nonluxated fracture of

the occipital condyle. Owing to consequent immobilization by means of cervical orthosis, pain

disappeared after the first 48 hours. Follow-up examination 4 weeks later showed no neurologic deficits.

The boy had no severe impairment of movements at the cervical spine.

D 2006 Elsevier Inc. All rights reserved.

The presence of an occipital condyle fracture after head

injury is seldom seen, especially when diagnosed in the

absence of neurologic deficits, or even worse, if it is

presented in childhood with nonspecific complaints.

1. Patient and method

A 15-year-old boy was playing on a carousel with his

classmates in the schoolyard. While driving around, he lost

hold and hit sandy ground with the left side of his head.

Trauma was reported as an axial torsion movement. At the

scene of the accident, the boy had his cervical spine

Elsevier Inc. All rights reserved.

urgische Klinik, Albert-Einstein-

ermany. Tel.: +49 731 50041951;

klinik-ulm.de (T. Kapapa).

immobilized by a stiff-neck collar (Laerdal Medical GmbH

& Puchheim, Germany). No initial loss of consciousness or

signs of neurologic deficits were observed. At the emergency

department, the boy reported a progressive pain in the neck as

well as at the left cervical trigonum after palpation. He kept

his head in a fixed position. Subsequent neurologic exami-

nation showed no abnormalities. Computed cranial tomog-

raphy (CT) excluded intracranial signs of trauma. An axial

spiral CTscan (1.25-mm slice thickness) with high-resolution

algorithm gave hints of irregularity of the craniocervical

junction. Two-dimensional reformation of the craniocervical

junction and the remaining cervical spine showed a fracture

of the left occipital condyle without dislocation of the

fragment (Figs. 1 and 2). The medulla was not affected.

Hence, there was no need for acute neurosurgical interven-

tion. After being provided with a rigid collar, the boy was

given light pain medication and was monitored under clinical

conditions. Pain medication was discontinued after 48 hours.

Journal of Pediatric Surgery (2006) 41, 1774–1776

Page 2: Fracture of the occipital condyle caused by minor trauma in child

Fig. 1 Computed tomogram showing a fracture of the occipital

condyle at the left side.

Table 1 Classification of condylus occipitalis fractures by

Anderson and Montesano [12]

Fracture

type

Fracture Stability

1 Impacted condyle with

comminution, no displacement into

the foramen magnum

Stable

2 Basal skull fracture with extension

into the occipital condyle without

any displacement

Stable

3 Avulsion fracture with injury

of the ligamentum alare

Potentially

stable

Fracture of the occipital condyle caused by minor trauma in child 1775

The young patient was discharged after 5 days without

any neurologic signs and was prescribed the cervical Miami

J Collar for 4 more weeks.

At follow-up examination 4 weeks later, the boy was still

in good condition without any deficits. Pain in the neck

occurred intermittently after mindless movements and

disappeared fast. A CT scan showed a reorganization of

fracture fragments. We decided to remove the orthosis.

2. Discussion

Fracture of the occipital condyle is often reported to be

an unusual lesion compared with other described injuries of

Fig. 2 Computed tomogram excluding affecting of the medulla

by fractured parts of the left condyle.

the human spine. An incidence of 4.2% was found in

autopsies of fatal traffic accident victims [1]. The first cases

reported in the literature had major head trauma with

impaired consciousness, and most cases had major trauma

[1-5]. Numbers of reported cases increased with advances in

CT imaging and awareness of their existence [6].

The clinical presentations vary from absence of neuro-

logic deficits to lower cranial nerve palsies. These palsies

could be with delayed presentation [7]. This is one of the

reasons why this potentially lethal fracture could be missed.

Standard radiographic examinations after admission into the

emergency department are important in the management of

spine injury but have considerable limitations in these cases.

High-resolution CT is the only method to exclude this

fracture definitely. Especially, reformatted 2-dimensional

CT may show this fracture in childhood even when points of

growth joints appear unfinished.

In most cases, patients were older than 21 years. Hence,

we lack information concerning the presence of occipital

condyle fracture in children or in adolescent patients. There

are some cases reported in younger patients who were also

involved in severe accidents like older persons [2,5,6,8-11].

Very little is reported about younger subjects and minor

traumas that can cause an occipital condyle fracture. Indeed,

falling from a donkey or from a carousel is a trauma, but com-

pared with a high-energy accident, it has a lower grade of

power of impact [6]. Regarding the rare cases of young vic-

tims with minor trauma and the trauma mechanism, fracture

of the occipital condyle could occurmore often than expected.

In our case, the young boy had no neurologic deficits.

Based on the classification of Anderson and Montesano, this

fracture is categorized as type I (Table 1) [12]. It is an

impacted condyle fracture with comminution, but without

displacement into the foramen magnum. Anderson and

Montesano considered this sort of fracture to be stable. The

mechanism of injury was believed to be axial loading. These

considerations agree with our case.

3. Conclusion

In case of unexplained posttraumatic neck pain, espe-

cially in the absence of neurologic deficits and nonspecific

Page 3: Fracture of the occipital condyle caused by minor trauma in child

T. Kapapa et al.1776

complaints, the craniocervical junction should be assessed

by CT scan even in young patients with minor trauma.

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